Clinical Investigation
Imaging and Diagnostic Testing
Determining myocardial viability in chronic ischemic left ventricular dysfunction: A prospective comparison of rest-redistribution thallium 201 single-photon emission computed tomography, nitroglycerin-dobutamine echocardiography, and intracoronary myocardial contrast echocardiography

https://doi.org/10.1016/j.ahj.2005.06.023Get rights and content

Background

Detection of viable myocardium (VM) has important therapeutic implications for chronic ischemic left ventricular (LV) systolic dysfunction. We compared the ability of nitroglycerin-dobutamine echocardiography (NTG-DE), intracoronary myocardial contrast echocardiography (MCE), and rest-redistribution thallium 201 single-photon emission computed tomography (RRT-SPECT) to detect VM in this setting.

Methods

Patients with LV ejection fraction (LVEF) <40% and multivessel coronary disease suitable for revascularization underwent NTG-DE, MCE, RRT-SPECT, and radionuclide ventriculography to determine baseline LVEF. Myocardial contrast echocardiography was performed using intracoronary injection of Albunex. Patients who underwent revascularization had 3-month postprocedural radionuclide ventriculography and transthoracic echocardiography to assess functional recovery.

Results

Of 512 myocardial segments in the 32 patients studied, 309 were akinetic or dyskinetic at baseline. Nitroglycerin alone increased regional thickening in 20% of segments with contractile reserve. By RRT-SPECT, 93% of nitroglycerin-responsive segments were viable. Myocardial contrast echocardiography had up to 85% sensitivity and 74% specificity for detection of VM diagnosed by RRT-SPECT. In the 23 patients who underwent revascularization, 54% of akinetic segments showed improved contractility, and mean LVEF increased from 32% to 37% (P = .04). Sensitivities and specificities for detecting functional recovery were 95% and 37% for RRT-SPECT, up to 87% and 48% for MCE, and 63% and 83% for a biphasic response during NTG-DE.

Conclusions

In patients with chronic ischemic LV dysfunction, RRT-SPECT had the highest sensitivity, and NTG-DE, the best specificity for detection of VM. Nitroglycerin facilitated detection of VM and may be a useful adjunct to dobutamine stimulation.

Section snippets

Methods

We prospectively recruited patients referred for clinically indicated coronary angiography. Intracoronary MCE was performed after angiography for patients who had (1) LV ejection fraction (LVEF) <40% by transthoracic echocardiography (TTE), (2) significant multivessel disease (≥50% diameter stenosis), and (3) coronary anatomy suitable for revascularization.

Contraindications to participation were (1) myocardial infarction, coronary artery bypass grafting surgery, or percutaneous coronary

Results

Characteristics of the 32 patients are detailed in Table I.

Discussion

The present study evaluated a variant pharmacologic stress protocol, comprising multistage dobutamine administration at low and moderate doses,3, 13 longer-stage duration,14 and front-loading with nitroglycerin. Biphasic RWM, considered most predictive of viability,13 was observed at dobutamine doses ≤20 μg/kg per minute in 97% of responsive segments. The initial improvement (mode 5 μg/kg per minute) and subsequent worsening of contractility in RWM (most at 10-15 μg/kg per minute) were observed

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